Fillable The Beneficiary Selection Form - Option D allows (Town of Oak Bluffs)

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The Beneficiary Selection Form - Option D allows (Town of Oak Bluffs)

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Introduction
Beneficiary Selection Form - Option D (If Member Dies Before Retirement)
Pursuant to Massachusetts General Laws, Chapter 32, Section 12(2)(d)
Form Last Revised: February, 2020
PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
FIVE MIDDLESEX AVENUE, SUITE 304 | SOMERVILLE, MA 02145
The Beneficiary Selection Form - Option D allows a member to select an eligible beneficiary to receive an allow-
ance if the member dies before retirement. This is the Member Survivor allowance described at
Massachusetts General Laws, Chapter 32, Section 12(2)(d) ("Option D").
The following needs to be kept in mind:
• This form must be filed with the retirement board.
• If you designate an eligible beneficiary on this form, and that beneficiary is living at the time of your
death, the money in your annuity account will not be disbursed to anyone in a one-time, lump-sum
payment, even if you have named them to receive such money on your Beneficiary Selection Form for
Refund of Accumulated Deductions.
• You may name only one person as the Option D beneficiary. That one person may be your spouse,
your former spouse who is not remarried at the time of your death, your child, your father, your
mother, your sister or your brother.
• If you select a beneficiary other than the spouse to whom you are married at the time of your death,
your selection on this form may be superseded by the eligible spouse under the provisions of Option
D if you die before retirement.
• If your personal situation changes (e.g. divorce, a domestic relations order goes into effect, your
beneficiary dies), you should file a new form with your retirement board.
• If you file a new Option D form with your retirement board, it will supersede any and all prior Option D
forms previously filed by you.
• When you sign this form, it should be witnessed by a disinterested party.
• To cancel an Option D beneficiary designation prior to retirement, your written notice must be filed
with the retirement board.
• This form becomes void upon your retirement.
Beneficiary Selection Form - Option D (If Member Dies Before Retirement)
Pursuant to Massachusetts General Laws, Chapter 32, Section 12(2)(d)
Form Last Revised: July, 2019 2
Choice of Option D Beneficiary
I, (Print Name) , a member of the
Retirement System, hereby nominate the beneficiary listed below, under the provisions of Massachusetts General Laws,
Chapter 32, Section 12(2)(d) to receive from the retirement system a benefit equal to the Option C retirement allowance which
would otherwise have been payable to me, in the event that I die before being retired.
I understand that I may change my beneficiary designation at any time prior to my retirement and that upon my retirement this
form becomes void.
I understand that this choice of Option D Beneficiary can be superceded if, at my death, I have at least two years of creditable
service and leave a spouse to whom I have been married for over one year and with whom I am living on the date of my death,
or if living apart, doing so for justifiable cause as determined by the Retirement Board.
Beneficiary
This person is my:
Parent Sibling Unmarried Former Spouse*
Spouse* Child
Name of Eligible Beneficiary:
Beneficiary's Date of Birth:
(attach birth record)
Beneficiary's Social Security #:
Beneficiary's Street Address:
City/Town:
State:
Zip Code:
*If beneficiary is your spouse or former spouse, a copy of your marriage certificate is required
To Be Completed By Witness (should be disinterested party):
Print Name:
Street Address:
City/Town: State:
Zip Code:
Signature: Date:
Member's Signature:
Print Name:
Signature: Date:
Name of Retirement Board:
Address:
City/Town: Zip Code:
Telephone: Fax:
Retirement Board: Please enter your retirement board information here.
Member's Information:
***-**-___ ___ ___ ___
Member's Last Name Member's First Name Social Security # (last four)
Street Address:
City/Town: State: Zip Code:
Email:
Phone:
DUKES COUNTY CONTRIBUTORY RETIREMENT SYSTEM
9 AIRPORT ROAD, SUITE 1
VINEYARD HAVEN
02568
(508) 696-3846
(508) 696-3847
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Completed 17 January 2021

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